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Participation in and Perceptions of Unprofessional Behaviors Among Incoming Internal Medicine Interns
To the Editor: Medical educators and the public are increasingly concerned about threats to physician professionalism.1 However, little is known about unprofessional behaviors among incoming internal medicine interns. This study assessed participation in and perceptions of unprofessional behaviors among entering medicine interns at the University of Chicago Medical Center and 2 independent residency programs affiliated with Northwestern University at the time of the survey.
Methods
Based on a prior survey of third-year medical students2 and input from residents and faculty, we developed a 28-item anonymous survey to assess participation in and perception of unprofessional behaviors related to residency. Domains included misrepresentation (introducing a student as doctor), fraud (falsifying medical records), shift work mentality and duty hours (signing out work you could have done so you can leave early), and on-call etiquette (celebrating a blocked admission). Behaviors ranged from egregious (making fun of patients) to controversial (attending a dinner sponsored by a pharmaceutical company). Participants reported whether they had ever participated in a behavior and rated their perception of this behavior as unprofessional on a Likert scale ranging from 1 (unprofessional) to 5 (professional). Surveys were administered at a required orientation at 1 site and electronically at 2 other sites between July and September 2007. An introductory paragraph emphasized survey anonymity and the importance of truthful responses. This study was determined to be exempt from review by the University of Chicago and Northwestern University institutional review boards.
Descriptive statistics were used to summarize participation in unprofessional behaviors. To test the association between participation and perception, site-adjusted analysis of variance was used. To account for multiple comparisons, statistical significance after Bonferroni correction was defined as P < .0018. Analyses were performed using Stata 10.0 (StataCorp, College Station, Texas).
Results
A total of 110 of 118 interns (93.2%) completed the survey (4 nonresponders and 4 surveys with missing data from site with paper survey). Making fun of patients to colleagues, falsifying medical records, and reporting patient information as normal when uncertain of the true results were perceived as most unprofessional (lowest Likert score) but were reported in 17%, 13%, and 10% of respondents, respectively (Table). Staying past the required shift limit to complete a patient care task that could have been signed out was considered the least unprofessional behavior (mean score, 3.52) and 78% of interns reported doing so. Answering family questions during cross-coverage, attending a pharmaceutical company–sponsored dinner or social event, and blocking an admission were among the least unprofessional, with mean scores of 3 or higher. There were no significant differences between categorical and preliminary interns or differences between sites. In site-adjusted analyses of variance, participants in 14 behaviors were less likely than nonparticipants to perceive the behavior as unprofessional (Table). For example, interns who reported signing out early were less likely than nonparticipants to view this behavior as unprofessional (3.11 vs 1.63; P < .001).
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Table. Self-reported Participation in and Perceptions of Behaviors Among Internal Medicine Interns (N = 110)
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Comment
Incoming internal medicine interns in 3 residency programs reported participating in behaviors that they recognize as unprofessional, although participants were less likely to perceive their behavior as inappropriate. A national study of practicing physicians demonstrated that physician behavior does not conform to the professional standards they support.3 Our findings highlight that this disconnect may emerge during training. There may be confusion or disagreement regarding what is unprofessional, possibly due to lack of education. Learning environments may promote participation in unprofessional behaviors, with participants perceiving the behavior as appropriate in order to resolve cognitive dissonance.4 A resurvey of this cohort is under way to assess changes during internship. Studies with broader representation are needed to assess whether participation in and perception of unprofessional behaviors occurs among trainees in other specialties and in other institutions and to determine whether such perceptions and behaviors change with increased duration of residency training.
Author Contributions: Dr Arora had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Arora, Wayne, Humphrey.
Acquisition of data: Arora, Wayne, Anderson, Didwania, Humphrey.
Analysis and interpretation of data: Arora, Wayne, Anderson, Humphrey.
Drafting of the manuscript: Arora.
Critical revision of the manuscript for important intellectual content: Arora, Wayne, Anderson, Didwania, Humphrey.
Statistical analysis: Arora.
Administrative, technical, or material support: Arora, Wayne, Anderson, Didwania, Humphrey.
Study supervision: Humphrey.
Financial Disclosures: Dr Arora reported receiving honoraria from the American Board of Internal Medicine. Drs Arora, Wayne, Anderson, Didwania, and Humphrey reported being members of the Association of Program Directors of Internal Medicine. Dr Humphrey reported receiving honoraria from the American Board of Internal Medicine and having been president of the Association of Program Directors of Internal Medicine.
Funding/Support: This study was funded by the University of Chicago Pritzker School of Medicine, Northwestern University Feinberg School of Medicine, and Evanston Northwestern Healthcare.
Role of the Sponsor: The funding sources had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
Additional Contributions: Shalini Reddy, MD; Jeanne Farnan, MD; and John Yoon, MD, University of Chicago, assisted in survey development and testing. Meryl Prochaska, BA, University of Chicago, provided assistance in editing and manuscript preparation. None of these persons received compensation for their role in the study.
Vineet M. Arora, MD, MAPP
varora{at}medicine.bsd.uchicago.edu
Department of Medicine
Pritzker School of Medicine
University of Chicago
Chicago, Illinois
Diane B. Wayne, MD
Department of Medicine
Feinberg School of Medicine
Northwestern University
Chicago
R. Andy Anderson, MD
Department of Medicine
Evanston Northwestern Healthcare
Evanston, Illinois
Aashish Didwania, MD
Department of Medicine
Feinberg School of Medicine
Northwestern University
Holly J. Humphrey, MD
Department of Medicine
Pritzker School of Medicine
University of Chicago
1. Hafferty FW. Professionalism: the next wave. N Engl J Med. 2006;355(20):2151-2152.
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2. Reddy ST, Farnan JM, Yoon JD; et al. Third-year medical students' participation in and perceptions of unprofessional behaviors. Acad Med. 2007;82(10)(suppl):S35-S39.
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3. Campbell EG, Regan S, Gruen RL; et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147(11):795-802.
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4. Festinger L. A Theory of Cognitive Dissonance. Stanford, CA: Stanford University Press; 1957.
Letters Section Editor: Robert M. Golub, MD, Senior Editor.
JAMA. 2008;300(10):1132-1134.
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